Load-modifying interventions for shin pain: A systematic and critical review of the evidence

Abstract

Introduction: Activity-related shin pain commonly presents in high-performance and community-level athletes. Pathoanatomical diagnoses and management are typically within a tissue pathophysiology, clinical-reasoning paradigm. Oftentimes a loading mechanism is conceptualised, including relative acute and accumulating energy exposures, and tissue responses, typically with discernible clinical presentations. It is therefore postulated that the spectrum of shin pain diagnoses could all respond to load-modifying interventions, regardless of the pathoanatomical diagnosis. Taking this approach, we conducted a systematic review and critique of evidence on load-modifying interventions for activity-related shin pain conditions. Methods: A systematic review was conducted according to PRISMA guidelines. Five databases were searched for randomised controlled studies investigating any non-surgical intervention that could conceivably modify tibial region tissue load, intending to manage activity-related anterior-anteromedial shin pain. We were interested in effect(s) on self-reported symptoms and function, physical performance, biomechanical measures, safety and feasibility. Study quality was evaluated with the Cochrane Collaboration Risk of Bias Tool V2 with the GRADE method determining the level of certainty for the findings. Available evidence was further critically reviewed to propose practice recommendations and clinical utility. Results: Of 16 468 studies screened, six individual studies reporting seven comparisons were included. Interventions considered to modify tibial load included braces, anti-pronation taping, a compression stocking and a stretch/strengthening program. These studies were assessed as having unclear or high risk of bias meaning there is low confidence in the aggregated study findings. Braces were associated with adverse effects and acceptability was limited by inconvenience, aesthetics and brace discomfort. Discussion: The low-quality evidence, which focused on passive interventions and/or failed to determine the effects of graded return to activity programs, does not support the clinical utility of any specific load-modifying interventions. No studies investigated other potentially load-modifying interventions including weight-loss, relative rest or gait modification. We therefore recommend clinical management is based on mechanistic principles of load management and pain science, with a contemporary patient-centred approach and consideration of the range of load-modification opportunities and the whole person’s symptom experience. The paucity of high-quality evidence demonstrating intervention efficacy for people with activity-related shin pain furthermore supports the urgent need for research to inform clinical practice. Conflict of interest statement: The authors have no conflict of interest to declare in relation to this study.